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NOTICE
OF PRIVACY PRACTICES
THIS
NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED,
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Our
Legal Duty
Psychology
Associates of the Fox Cities (PA-FC) is committed to protecting the privacy
of our clients confidential health information. We are required by law
to:
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Maintain
the privacy of your health information; and, |
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Provide
you with this notice of our legal duties and privacy practices with
respect to your personal health information. |
If you have
any questions about any part of this notice or if you want more information
about the privacy practices at PA-FC, please contact us using the information
listed at the end of this notice.
Effect
Date of This Notice
This notice
takes effect April 14, 2003, and will remain in effect until we replace
it. We reserve the right to change our privacy practices and the terms
of this notice at any time. The terms of this notice apply to all designated
PA-FC records containing your protected health information that are created
and maintained by our clinic. Any changes to the Notice will be effective
for all of your records created or maintained in the past as well as any
records we create or maintain in the future. We will post a copy of the
most current Notice in a prominent location within our facility and on
our web site. PA-FC will abide by the terms of the notice currently in
effect. At any time, you may request a copy of our most current Notice.
You will be asked to acknowledge receipt of the Notice of Privacy Practices
in writing.
Who
will Follow Our Privacy Practices
PA-FC provides
psychological care to our clients in partnership with physicians and other
professionals and organizations. Our privacy practices will be followed
by:
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Any
health care professionals who care for you at PA-FC. |
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All
locations that are staffed by our workforce. |
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All
members of our clinic workforce including therapists, consultants,
and staff members. |
Purposes
for Which We Use and Disclosure Your Health Information
We are committed
to ensuring that your health information is used responsibly by our organization.
We may use and disclose your health information, without your written
authorization, for the following purposes:
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Treatment:
We may use or disclose your health information for treatment purposes.
While you are a client at our clinic, we may find it necessary to
share your health information with other staff members involved
in your care. We may also share your health information with other
healthcare organizations that may participate in your care and treatment
such as another clinician or hospital (for emergent care reasons).
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Payment:
Your health information may be used or disclosed without your consent
for payment purposes. It may be necessary for us to disclose your
health information so that we may bill and collect from you, your
insurance company or other party responsible for payment for the
treatment and services provided.
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Health
Care Operations: Your health information may be used for our organizational
operations that are necessary to ensure that we provide the highest
quality of care. For example, your health information may be used
for performance improvement purposes.
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Information
Provided to You: We may use your health information to assist
us in communicating with your appointment reminders, test results,
and treatment information. We may also use and disclose your health
information to inform you of health related benefits or services that
we or an affiliated entity provides that may be of interest to you.
Our communications to you may be by phone or by mail.
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Notification
and Communication With Family and Friends: We may share health
information about you with family members or friends who are involved
in your clinical care. If you are unable or unavailable to agree or
object, our health professionals will use their best judgment in communicating
with your family and others.
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Required
by Law: We may use or disclose your health information only as
allowed by law. Examples of situations where we may be required or
permitted to release your health information include:
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| a. |
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to report
child and /or adult abuse, neglect, or domestic violence; |
| b. |
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for
health care oversight activities; |
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for
judicial and administrative proceedings; |
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to law
enforcement officials pursuant to subpoenas and other lawful processes,
concerning crime victims, identifying or locating a suspect, fugitive
materials witness, or missing person; |
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to coroners,
medical examiners and funeral directors; |
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to avert
a serious threat to health or safety of the general public; |
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for
specialized government functions such as military and veterans activities,
national security, and intelligence activities; |
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to correctional
institutions and law enforcement regarding inmates; and |
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for
worker’s compensation purposes.
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Research:
In certain situations, we may use and share your health information
for research purposes. However, all research projects are subject
to special review and approval process designed, among other things,
to ensure the privacy of your health information.
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Fund-raising:
PA-FC does not engage in any fund raising activities. We do not sell
or provide client information for any reason; therefore, you should
not respond to any solicitation of “donations” on behalf
of PA-FC.
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Disaster
Relief: We may use or disclose your name and location to a public
or private entity authorized by law or by its charter is assist in
disaster relief efforts. |
Other
Purposes For Which We Use and Disclosure Your Health Information
In any other
situations not covered by this Notice as noted above, we will ask for
your written authorization before using or disclosing information about
you. If you choose to authorize disclosure of information about you, you
can later revoke that authorization at any time by notifying us in writing
of your decision.
Your
Rights Regarding Your Health Information
As a client
of PA-FC you have certain rights to regard to the health information that
is maintained by our organization. These rights are as follows:
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Access:
With few exceptions, you have the right to access and receive a
copy of your health information. The request must be made in writing.
If you request a copy, it should be requested in advance and we
may charge for the cost of coping, postage and/or other related
supplies. In certain situations, we may deny your request. If we
deny your request, we will tell you, in writing, why your request
was denied and explain to you your right to have the denial reviewed.
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Disclosure
Accounting: You have a right to receive a list or accounting of
those disclosures, which PA-FC has made regarding your health information
for purposes other than treatment, payment healthcare operations,
information provided directly to you, and information disclosed as
a result of mandated government functions. The request must be made
in writing. Your request for the accounting must state a specific
time period which may not be longer than six years and may not include
dates before April 14, 2003. The first accounting in a 12 month period
is free. Other requests may be charge according to our cost for producing
the information.
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Amendment:
You have the right to request that your health information be amended
if you feel it is incorrect or incomplete. The request must be made
in writing. PA-FC will review the request and make a determination
as to whether or not an amendment will be made. If we did not create
the information that you feel is incorrect or incomplete, we may deny
your request. PA-FC will communicate to you in writing the final decision
on your request, as well as provide information to appeal a denial
of your request should it occur.
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Confidential
Communication: You have the right to request that we communicate
with you about your health information by alternative means or to
alternative locations. The request must be made in writing, and your
request must represent that the information could endanger you if
it is not communicated in confidence as you requested. We have the
right to decide whether the request is reasonable. We do not have
to comply with an unreasonable request.
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Restriction:
You have the right to request restrictions on certain disclosures
of your health information. The request must be made in writing. We
will consider your request and determine our ability to carry out
your request, while not compromising your care.
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Notice:
You have the right to receive a paper copy of this Notice of Privacy
Practices. You may ask us to give you a copy of this Notice at any
time or you may print a copy from our web site at WWW.PA-FC.COM. |
Questions
and Complaints
If you want
more information about our privacy practices, or if you would like to
exercise one or more of your rights regarding your health information,
please contact us using the information listed at the end of this notice.
If you are
concerned that your privacy rights may have been violated, or you disagree
with a decision we made about your rights to your health information,
you may complain to us using the information listed at the end of this
notice. The complaint must be made in writing. You may also send a written
compliant to the Secretary of the U.S. Department of Health and Human
Services Office of Civil Rights. We will provide you with the address
to file your complaint with the U.S. Department of Health and Human Services
upon request. We support your right to the privacy of your health information.
We will not retaliate in any way if you choose to file a complaint with
us or with the U.S. Department of Health and Human Services.
You may contact
us using the information listed below:
Psychology Associates Fox Cities
Privacy Officer
2557 E Calumet St
Appleton WI 54915
Telephone:(920) 738-9999
Email: info@pa-fc.com
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